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Two Topics Under Discussion: Infection Control Policy I am an Infection Control nurse and have recently worked with our cardiac cath lab to revise their infection control policy. My references included: CDC guidelines for prevention of surgical site infections, APIC (Association for Professionals in Infection Control and Epidemiology) text (Cardiac Cath Lab section), AORN standards, and OSHA’s Bloodborne Pathogens Regulation. Below is our revised policy. Staff must: 1. Wear hair covers when in the procedure rooms 2. Wear masks during set-up and procedure 3. Wear protective eyewear for personnel within the sterile field or those close to the sterile field during procedures 4. Prepare sterile fields as close to the time of use as possible and that sterile fields should not be covered 5. If a pre procedure skin shave must be done, use a clipper instead of a razor. I would greatly appreciate any assistance with the above issues. Thank you very much! Janet, RN, Infection Control/ Clinical Review Contrast Allergies Do you have a policy or standard of practice regarding contrast allergies and/or a pre-treatment protocol for patients with a history of iodine/contrast allergy for both cath lab or interventional radiology cases? Norman Jacinto, BSN, RN, CVI Systems Administrator Cardiac & Vascular Institute at Memorial Regional Hospital Group Members Respond to Advice on Infection Control: Pacemakers, RHC, LHC, Biopsy During pacemakers, all staff in the room wear a mask and a hat. The door to the room is kept closed to limit any persons coming in and out. The scrub person sets up the tray once the patient is in the room. The scrub person and MD do a five-minute scrub and they wear eye protection. The patient gets a scrub, also nipple line and above. While we scrub the patient’s chest, the patient wears a mask and hat. We take the mask off after the patient is draped but leave the hat on. In RHC, LHC PCIs, the scrub person wears a hat and mask. Other staff in the room wear a hat. A mask and hat are worn when setting the tray up. We try to set the trays up as close to the case as possible and we do not cover the trays once they are set up. All staff wear a hat and mask during cardiac biopsy procedures. The scrub person always wears eye protection. Annie Ruppert RN, Annie.Ruppert@sharp.com Some items standard 1. Wear hair covers when in the procedure rooms. Answer: Should be standard 2. Wear masks during set-up and procedure. Answer: Standard for scrub person, optional for circulator 3. Wear protective eyewear for personnel within the sterile field or those close to the sterile field during procedures. Answer: Standard for scrub person 4. Prepare sterile fields as close to the time of use as possible and that sterile fields should not be covered. Answer: If it is a wet table, it should not be set more than 1 hour. Dry tables may be to left for 2 hours if needed but this is not recommended. Someone should be in attendance if a sterile table is set up and covered. 5. If a pre procedure skin shave must be done, use a clipper instead of a razor. Answer: We use a razor, but I understand the clippers are safer with less infection, even though we have not had any post infections. Larry Sneed sneelarr@armc.com Physician and scrub person In our lab, only the physician and the scrub person wear the hair cover and mask and protective eye wear. As a side note, we also wear t-shirts under our scrub wear, but not turtleneck shirts. Masks and hair wear are also required when setting up the tray. We do set up the tray as close to the start time as possible and do not make up multiple trays and then cover them. We have used the clipper assembly for about 7 years (3M does not charge us for the handle, only the blades if cost is a factor). Patricia Coblentz PatriciaACoblentz@ProvenaHealth.com Advise utility drapes for sterile field We require hair covers in the procedure rooms when we have an open tray. Masks are required in the device implantations and when you are the scrub person, as well as for setting up the tray. Protective eyewear should be worn whenever there is the risk for blood or body fluids, so the scrubber wears glasses, preferably lead for their protection, and the nurses also wear disposable glasses when they are near body fluids, for the LV injections, etc. We currently prepare our sterile field with utility drapes to make the outline of the sterile field so it is above the area of interest, both sides and at the bottom. The utility drapes are used because they have an adhesive edge to them and won't move or shift. We tried them midline; however, the tape managed to adhere to the personables, so we use a sterile towel down the middle. Our patients are clipped midline to mid lateral thigh, and half way to the knee to allow for a sterile, clipped area in the case of a balloon pump insertion. Both sides are clipped so we don't have to disturb the sterile field to clip the opposite side if it is needed. We also clip the patient in the holding/prep area, and cleanse the area with a Chloroprep stick and will wash the peri area if necessary. The hair that is clipped is picked up with tape or a sticky mitt. Connie csgehin@yahoo.com Confirmation of guidelines The listed guidelines are the exact guidelines my current lab uses and the same as my previous lab in California used. We also wipe down with disinfectant all equipment that touched a patient during the procedure after the patient is removed from the table. Gloria Nolan RN, Director Cath Lab Gloria.Nolan@HCAHealthcare.com Experiences vary First: you have done some good homework. The one thing that many Infection Control (IC) people who have not worked in the cath lab have a hard time understanding is that our procedures are clean procedures. If a pocket is made, then that would be a sterile procedure. With that being said, the same standards do not need to be met for patient safety but may for staff safety. I have never seen an infection from a cath procedure. Many IC professionals have difficulty with this concept because we are all trained that if something is being done invasively it has got to be a sterile procedure. To be honest, I did too when I first came to the lab. Talk with your cardiologist and staff to understand the differences. AORN is a very good organization, but their standards are for the OR and not the cath lab. Wearing hair covers when in the procedure rooms is not a bad idea, but understand that there are many labs who do not wear a hair cover even when scrubbed, with no infections resulting. Wearing masks during set-up and procedure is a good idea for pacer and pocket procedures but a bit of an overkill for a cath. Wearing protective eyewear for personnel within the sterile field or those close to the sterile field during procedures is a good idea. I have been nailed in both eyes with a bloody solution when a MD was flushing the system. However, those who are circulating should not need to wear protective glasses. Re: Preparing sterile fields as close to the time of use as possible and that sterile fields should not be covered. At one hospital where I work, we set up tables once the patient is in the room. At another hospital, we set up all the tables in the morning. Unless you have fluids on the table it can be covered without worry. Re: If a pre procedure skin shave must be done, use a clipper instead of a razor. At both of my hospitals, we only use clippers. Kevin BS, RN, RCIS ldrich3@comcast.net 2nd Email Discussion Topic: Contrast Allergies Do you have a policy or standard of practice regarding contrast allergies and/or a pre-treatment protocol for patients with a history of iodine/contrast allergy for both cath lab or interventional radiology cases? Norman Jacinto, BSN, RN, CVI Systems Administrator, Cardiac & Vascular Institute at Memorial Regional Hospital Both hospitals pretreat If someone is suspected of having a contrast allergy or is allergic to shellfish at both hospitals I work at will pretreat with benadryl, pepcid, and either solucortef or solumedrol. Kevin BS, RN, RCIS, ldrich3@comcast.net 2 hours prior Concerning contrast dye allergy (known or suspected) we have the patient receive, at least 2 hrs prior to the procedure, 1-2mg/kg of solumedrol, then 50 mg benadryl i.v. We rarely gave any H2 blockers for it (I can recall perhaps twice). Tim Revell, trev_7777@hotmail.com Physician preference Our physicians address that in their pre-procedural visit. We currently do not have a policy on pre-meds for allergic patients. Each physician uses their own selection of pre-meds. Steve Gressmire RT(R)(CV) ARRT, AAMA, Cardiology Services Director, Northwest Mississippi Regional Medical Center, Clarksdale, MS, Steve.Gressmire@nwmrmc.hma-corp.com Literature on contrast allergies I did a Medline literature search on this topic because several of our cardiologists and radiologists want a standard protocol for patients with contrast allergy. We have not put it all into a standard yet, but below is the summary of the articles that I reviewed. Maybe it will be of some help. Annie Ruppert, Annie.Ruppert@sharp.com SUMMARY OF ARTICLES ON RADIOCONTRAST MEDIA ALLERGIES AND REACTIONS All of the articles dealt with contrast allergies and patients who had documented history of contrast allergy and/or reactions. There were, in general, five pretreatment regimens recommended: 1) Prednisone 50mg po every 6 hours times 3 doses with the last dose being given 1 hour prior to the study. Benadryl 50 mg po or IM given 1 hour prior to the study 2) Prednisone 50mg po 13 hours prior to the study 7 hours prior to the study 1 hour prior to the study Benadryl 50mg po/IM 1 hour prior to the study 3) Prednisone 50mg po 13 hours prior to the study 7 hours prior to the study 1 hour prior to the study Benadryl 50 mg po/IM 1 hour prior to the study Ephedrine 25mg po 1 hour prior to the study. (Ephedrine usually is contraindicated in patients with angina, arrhythmia, hypertension) 4) Prednisone 40 mg po every day times 3 days 5) Prednisone 50 mg po every 6 hours up to 18 hours prior to the procedure and for 12 hours after the procedure In the setting of an emergent study when there is no time to pre-medicate and the patient has a documented contrast allergy, the following pre-treatment regimen was utilized. 1) Hydrocortisone 100-250mg IV every 4 hours until the study is complete. Benadryl 50 mg po/IM 1 hour prior to the procedure Ephedrine 25 mg po 1 hour prior to the procedure (Ephedrine was withheld in patients with angina, arrhythmias and/or other contraindications) The usual dose of Hydrocortisone given was 200mg IV The use of Tagamet is controversial since no real benefit was seen in study groups who received Tagamet, and it adds to cost and possible adverse reactions. Ephedrine is also controversial because there are several contraindications to the drug, such as hypertension and other cardiovascular diseases. Other Pre-treatment Modalities 1) Use of lower osmolar radio-contrast media is associated with a lower incidence of anaphylactoid reaction compared with higher osmolar radio-contrast media but is also more expensive. Use of low osmolar contrast is usually reserved for patients who are at high risk for a reaction: history of previous anaphylactoid reaction to contrast media, asthma, and reaction to skin allergens or penicillin. 2) It was suggested that if possible, beta blockers should be discontinued prior to the patient receiving contrast media. Patients who had asthma or exposure to beta blockers were found to be at a significantly higher risk for anaphylactoid reactions. This may be because of worsening of bronchospasm that some patients experience with contrast media. 3) Pretesting patients with a small amount of radio-contrast media was studied and results demonstrated that pretesting for allergy is a poor predictor of anaphylactoid reactions to radio-contrast media. For this reason, pretesting with radio-contrast media has for the most part been abandoned. Other Recommendations for Patients at Risk for Anaphylactoid Reactions to Radiographic Contrast Media 1) Evaluate necessity of a procedure requiring radiographic contrast media administration. 2) Have emergency anaphylaxis therapy and equipment available. Nausea, vomiting, flushing, and other minor side effects generally require no treatment. Urticaria and angioedema can be controlled with 25 to 50mg of Benadryl IV or IM and /or 0.3 ml of epinephrine (1:1,000) sq. Laryngeal edema and bronchospasm usually respond to epinephrine. Repeat doses of epinephrine, aminophylline, steroids and benadryl may be required in some patients. 3) Cardiac collapse can occur in two types. The first is manifested by bradycardia and the other by tachycardia. When hypotension is discovered, check the pulse rate. Hypotension with bradycardia signifies vagal mediation and should be treated with IV atropine. Hypotension with tachycardia is due to an anaphylactoid reaction with relative hypovolemia. Large volumes of IV fluids are usual treatment. The use of epinephrine, pressor agents and steroids may be necessary. All staff should be trained in basic life support procedures and physicians should be certified in advanced cardiopulmonary life support. 4) Obtain a detailed description of the past reaction from the patient and review the medical record for documentation of what the reaction was. 5) Inform the patient of the risks, explain the need for the procedure and document all of this in the medical record.
References
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